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Determine Requirement for the
Patients
Pranithi Hongsprabhas MD.
Division of Clinical Nutrition,
Department of Medicine, Faculty of
Medicine, KKU
Objectives
• Energy metabolism, normal protein,
•
carbohydrate and lipid metabolism
Mechanisms that regulate substrate utilization
and energy production
•
•
•
Metabolic responses to starvation and metabolic stress
Effect of stress on metabolic rate and substrate
utilization
Determine calorie and protein requirements during
metabolic stress
• Methods for calculating nutritional
requirements
Energy Expenditure
 Basal energy expenditure~0.8-1.2 kcal/min
 Age
 Sex
 Body size (roughly with BSA): LBM
 Thermic effect of activity
 Thermic effect of food
 Metabolic stress
BMR: shortly after awakening, fast 8-12 hr,
thermoneutrally)
RMR: Resting energy expenditure (fast 2 hr, rest 30 min,
thermoneutrally) ~ 110%BEE
Nutrients
•
•
•
•
Protein
Carbohydrates
•enteral
•parenteral
Lipids
Vitamins
•
•
Water
Minerals
4 kcal / g
4 kcal / g
3.4 kcal / g
9 kcal / g
– Water soluble
– Fat soluble
– Electrolytes
– Trace elements and ultra trace minerals
Glucose Metabolism
Glucose
Glucose
CYTOPLASM
Cori
Cycle
MITOCHONDRIA
Pyruvate
Pyruvate
Krebs
Cycle
ATP
AcetylCoA
Lactate
Lactate
Lieberman MA, Vester JW. Carbohydrates. In: Nutrition and Metabolism in the Surgical Patient.
Boston, MA: Little, Brown and Company;1996:203-236.
Fatty Acid Metabolism
CAPILLARY
Triglycerides
CYTOPLASM
Fatty Acids
Carnitine
MITOCHONDRIA
Fatty Acids
Fatty Acids
+
Glycerol
ß Oxidation
ATP
Triglycerides
Fischer JE, ed. Nutrition and metabolism in the surgical patient. Boston, MA: Little, Brown and
Company; 1996.
Amino Acids
•
Essential
 Leucine
 Lysine
 Valine
 Threonine
 Isoleucine
 Phenylalanine
 Methionine
 Histidine
 Tryptophan
•
Conditionally essential
•
Non-essential
 Glutamine
 Arginine
 Alanine
 Tyrosine
 Aspartic Acid
 Glutamic Acid
 Cysteine
 Glycine
 Serine
 Proline
Fischer JE, ed. In: Nutrition and Metabolism in the Surgical Patient. 1st ed. Lippincott
Williams and Wilkins Publishers; 1996.
Nutrient Utilization
• Regulation
– Nutrient availability
– Hormonal environment
– Inflammatory state
Metabolic Response to Fasting
GLUCOSE UTILIZED (g/hora)
I
II
III
IV
40
V
Exogenous
Glycogen
Gluconeogenesis
30
20
10
LEGEND
I
II
III
FUEL FOR
BRAIN
GLUCOSE
GLUCOSE
GLUCOSE
IV
GLUCOSE,
KETONES
V
GLUCOSE,
KETONES
Ruderman NB. Annu Rev Med 1975;26:248
Body Response to Starvation: Early Stage
Alanine / Pyruvate
Glucose
Glycerol
Gluconeogenesis
FAT
Ketogenesis
Glutamine
Ketones
AGL
Ureagenesis
Ketones
Urea
NH3
Body Response to Starvation: Late Stage
Alanine / Pyruvate
Glucose
Glycerol
Gluconeogenesis
FAT
Ketogenesis
Glutamine
Ketones
AGL
Ureagenesis
Ketones
Urea
NH3
Metabolic Response to Starvation
Hormonal
Response
Starvation
Energy Expenditure
in to
Starvation
Nitrogen Excretion (g/day)
Hormone
12
Source
Change in Secretion
Norepinephrine
Sympathetic Nervous System
Norepinephrine8
Adrenal Gland
Epinephrine
Adrenal Gland


Normal Range

Thyroid Hormone
Thyroid Gland (changes to T3

Partial Starvation
4
T4
peripherally)
Total Starvation
0
10
20
Days
30
40
Long CL et al. JPEN 1979;3:452-456
Landberg L, et al. N Engl J Med 1978;298:1295.
Metabolic Response to Trauma
Flow Phase
Energy Expenditure
Ebb Phase
Time
Cutherbertson DP, et al. Adv Clin Chem 1969;12:1-55
Metabolic Response to Trauma
Endocrine
Response
Fatty Deposits
Fatty Acids
Liver & Muscle
(glycogen)
Glucose
Muscle
(amino acids)
Amino Acids
Metabolic Response to Surgical Trauma
Alanine / Pyruvate
Glucose
Glycerol
Gluconeogenesis
FAT
Ketogenesis
Glutamine
Ketones
AGL
Ureagenesis
Ketones
Urea
NH3
Metabolic Response to Trauma
Nitrogen Excretion (g/day)
28
24
20
16
12
8
4
0
10
20
30
Days
Long CL, et al. JPEN 1979;3:452-456
40
Glucose Metabolism During Starvation
and Critical Illness
Starvation Stress reaction
Gluconeogenesis +
+++
Glycolysis
-
+++
Glucose
oxidation
Glucose cycling
-
-
-
+++
Glucose oxidation decrease to 2-2.5
mg/kg/min (3-4 g/kg/d)
Lipid Metabolism During Starvation
and Critical Illness
Starvation Stress reaction
Peripheral
lipolysis
+++
++
Lipid oxidation
+++
+
Fatty acid
cycling
-
++
Protein Metabolism During Starvation
and Critical Illness
Starvation Stress reaction
Proteolysis
-
+++
Protein
synthesis
Amino acid
oxidation
-
+
-
+++
AA should be increased up to 1.5-2
g/kg/d
Calorie Distribution Shift in Catabolism
NORMAL
CATABOLIC
15%
30%
Protein
25%
25%
Fat
Fat
CHO
Protein
CHO
45%
60%
REE in Critically Ill Patient
70
62
Hypermetabolic
60
Normal Metabolic
50
Inappropriate
Hypometabolic
40
30
23
20
15
10
0
Hypermetabolic
Normal
Metabolic
Crit Care Med 1990;18:1320
Inappropriate
Hypometabolic
Effect of Illness
REE in Sepsis
200
161+22
REE (%)
175
155+14
Sepsis
Sepsis syndrome
Septic shock
Recovery from septic
124+12
150
102+24
125
100
Sepsis
Sepsis syndrome Septic shock Recovery from septic shock
Chioléro Rมet al. Energy metabolism in sepsis and injury. Nutrition 1997; 13 (suppl):
45S-51S
Stress Stratified According to
Metabolic Criteria
Stress
level
Urine N Plasma
(g/d)
lactate
Plasma
glucose
(mM)
(mg/dl)
Insulin
resistance
VO2
2
(ml/min·m )
Low
<10
<1.5
<150
No
<140
Moderate
10-20
1.5-3
150-250
Some
140-180
high
>20
>3
>250
yes
>180
Cerra FB. Multiple organ failure syndrome. In: Bihari DJ, Cerra FB, eds.Multiple organ failure
syndrome. Fullerton, California: Society of Critical Care Medicine, 1989:1-24
Effect of Treatment
Treatment
Catecholamine
E
NE
DA
DB
Nutrition Vol. 13, No. 9(Suppl), 1997
∆ REE (%)
(septic shock)
+15
+25
+4
+6
blocker
burn
Head injury
-7
-6
Sedative
Post op MV
Barbiturate: head trauma
-25-55
-32
Nutrition Vol. 13, No. 9(Suppl), 1997
Effect of Treatment
Treatment
∆ REE (%)
Analgesic
Post op
Critically ill
-66
-9
Muscle relaxant
HI
MV
Post op
ARDS
Cooling
Nutrition
Major burns
-42
-11
-25
-8
+20
Measure Energy Expenditure
2500
Expected
Measured
2000
1500
1000
Bakker JP et al. Gastroenterology 1984: 87: 53-9
Roulet M et al. Clin Nutr 1983; 2:97-105
McCall M et al. JPEN 2003;27: 27-35
HI
nonparalysed
Trauma
HI paralysed
Septic
Ventilated
0
Sepsis
Ventilated
500
Energy Expenditure in ICU
Kcal/d
Kcal/kg/d
1927
3257
25
47
Trauma wk1 2380
Trauma wk2 4123
31
59
Sepsis wk1
Sepsis wk2
Uehara M. et al CCM1999; 27:P1295-2
Stage of Diseases: Metabolism and
Chronic Critical Illness
EBB
EBB
FLOW
FLOW
SIRS/MODS
SIRS/MODS
TIME
Chronic critical illness
The development of chronic critical illness: decreased
TIME burnout
metabolism and endocrine
Prolonged hypermetabolism: SIRS and MODS
Determining Calorie Requirements
• Indirect calorimetry
• Harris-Benedict x stress factor x
activity factor
• 25-30 kcal/kg body weight/day
Calculating Basal Energy
Expenditure
Harris-Benedict Equation
– Variables: gender, weight (kg), height (cm),
age(yr)
Men:
66.47 + (13.75 x weight) + (5 x height) – (6.76 x
age)
Women:
655.1 + (9.56 x weight) + (1.85 x height) – (4.67 x
age)
Calorie requirement = BEE x activity factor x
stress factor
Metabolic Response to Starvation and
Trauma: Nutritional Requirements
Injury
Minor surgery
Long bone fracture
Cancer
Peritonitis/sepsis
Severe infection/multiple trauma
Multi-organ failure syndrome
Burns
Activity
Confined to bed
Out of bed
Stress
Factor
1.00 – 1.10
1.15 – 1.30
1.10 – 1.30
1.10 – 1.30
1.20 – 1.40
1.20 – 1.40
1.20 Factor
– 2.00
Activity
1.2
1.3
Example:
Energy requirements for
patient with cancer in bed
= BEE x 1.10 x 1.2
ADA: Manual Of Clinical Dietetics. 5th ed. Chicago: American Dietetic Association; 1996
Long CL, et al. JPEN 1979;3:452-456
Calorie Calculation
“Rule of Thumb”
Calorie requirement = 25 to 30 kcal/kg/day
Macronutrients during Stress
Carbohydrate
• At least 100 g/day needed to prevent
ketosis
• Carbohydrate intake during stress
should be between 30%-40% of total
calories
• Glucose intake should not exceed
5 mg/kg/min
Barton RG. Nutr Clin Pract 1994;9:127-139
ASPEN Board of Directors. JPEN 2002; 26 Suppl 1:22SA
Macronutrientes during Stress
Fat
• Provide 20%-35% of total calories
• Maximum recommendation for
intravenous lipid infusion: 1.0 -1.5
g/kg/day
• Monitor triglyceride level to ensure
adequate lipid clearance
Barton RG. Nutr Clin Pract 1994;9:127-139
ASPEN Board of Directors. JPEN 2002;26 Suppl 1:22SA
Determining Protein Requirements
•
•
•
•
Body weight
Age
Type of protein
Daily requirements:
Healthy

0.8 to 1.0 g/kg/day
Stressed state

1.0 to 2.0 g/kg/day depending on
condition
TUN Vs UUN In Critically Ill Patients
Receiving NS
 TUN = UUN+2
(UUN<10)
 TUN =
1.1UUN+2
(UUN>10)
 TUN = UUN
0.85
Dickerson RN, et al JPEN 2004;28:S24
Vitamins
Fat Soluble Vitamins
Vitamin A
Vitamin D
Water Soluble Vitamins
Folic Acid
Pantothenic Acid
Biotin
Niacin
Riboflavin
– Vitamin E
– Vitamin K
– Thiamin
– Vitamin B6
– Vitamin B12
– Vitamin C
Key Vitamins and Minerals
Vitamin A
Vitamin C
B Vitamins
Pyridoxine
Zinc
Vitamin E
Folic Acid,
Iron, B12
Wound healing and tissue repair
Collagen synthesis, wound healing
Metabolism, carbohydrate utilization
Essential for protein synthesis
Wound healing, immune function,
protein synthesis
Antioxidant
Required for synthesis and
replacement of red blood cells
Minerals
Sodium
Potassium
Chloride
Calcium
Phosphorus
Magnesium
Zinc
Copper
Chromium
Manganese
Selenium
Iodine
Iron
Summary
• Metabolic response to starvation is an adaptive
•
•
mechanism
Nutritional requirements increase during
metabolic stress
Energy Substrate Utilization
• Fasting state:
• Depends on nutrient availability
• In stress:
• Depends on hormonal environment and
inflammatory response
Adverse Effect of Overfeeding




Hepatic steatosis
Excess VCO2
Hyperglycemia
Hypo K, Mg, P
 Hypertriglyceridemia
 RES suppression
 Worsening gas
exchannge
Intensive Insulin Therapy in Critically Ill
Patients
Von den Bergh et al. NEJM 2001,345(19):1359
 A study on all patients during 1 year in
ICU
and need of ventilation (n= 1548)
 Randomized to conventional treatment
(n=783) or Intensive insulin treatment
(n=765) conventional
(Intensive: Blood glucose <110mg/dl; Conventional: Insulin if
>215 mg/dl)
 Fed according to needs, EN, PN or
combined
Intensive Insulin Treatment…
Van Den Berghe Et Al, NEJM 2001
In hospital survival %
100
96
Intensive treatment
92
P = 0.01
88
Conventional treatment
84
0
50
100
150
200
Days after admission
250
Effect of Caloric loading CHO Loading
What should We feed the critically ill
 High energy intake




Not required
Not prevent catabolism
Increased risk of complication
Intolerance to feeding, PN
 If intolerance: Permissive underfeeding
 Adequate protein intake!!!!
Jeejeebhoy KN. Nutrition in Clinical Practice 2004; 19: 477-480